A previously healthy 2-year-old suddenly developed coughing while playing with small toy beads. Since then she has intermittent cough with localized wheeze audible only over the right hemithorax. Expiratory chest radiograph shows the right lung hyperinflated with the mediastinum shifted to the left. Which is the next step in management?

• A Chest physiotherapy with postural drainage
• B A 7-day course of oral amoxicillin-clavulanate
• C Rigid bronchoscopy under general anesthesia ✓
• D High-dose inhaled salbutamol every 4 hours

Explanation

Sudden choking followed by unilateral wheeze and air trapping with contralateral mediastinal shift on the expiratory film is diagnostic of a radiolucent endobronchial foreign body, here obstructing the right main bronchus. Definitive removal is by rigid bronchoscopy under general anesthesia, which also secures the airway. Bronchodilators treat reversible bronchospasm but cannot relieve mechanical obstruction, physiotherapy risks dislodging the object distally, and antibiotics address infection rather than obstruction.

Reference: Nelson Textbook of Pediatrics, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.